Introducing Allergens to Infants and Preventing Allergies: New Recommendations and Thoughts
Tuesday, January 14, 2014 
Food allergies are on the rise in developed countries. It has become a significant source of fear for parents, who know that sometimes the smallest exposure to an allergen could kill their children in a matter of minutes. It has become a challenge for schools, daycares, and other institutions who want to ensure a safe environment for all children without being overly restrictive about the foods other children can bring with them. The implications of food allergies range from inconvenience to death. Parents of infants and young children, especially in families with a history of food allergies, want to do everything they can to protect their children. There is a lot of fear when introducing common allergens to high-risk infants and some families have even been known to go and sit in the parking lot of the Children's Hospital while introducing nuts or other allergens for the first time (even though Pediatrician Dr. Daniel Flanders noted to me on twitter that "ironically, the first introduction doesn't illicit a reaction. Only happens with subsequent exposures.").
Because of the high and ever-increasing prevalance of food allergies in Canada (7% among the general population, and >10% of one-year olds), the Canadian Paediatric Society (CPS) considers allergy prevention a key health goal. As a result of ongoing research, guidelines for health care providers has been updated in a number of countries including the United States, Europe and Australia in the past few years. In December 2013, CPS issued a joint statement along with the Canadian Society of Allergy and Clinical Immunology on Dietary Exposures and Allergy Prevention in High-Risk Infants. Their new recommendations are as follows (emphasis mine):
- Do not restrict maternal diet during pregnancy or lactation. There is no evidence that avoiding milk, egg, peanut or other potential allergens during pregnancy helps to prevent allergy, while the risks of maternal undernutrition and potential harm to the infant may be significant. (Evidence II-2B)
- Breastfeed exclusively for the first six months of life. Whether breastfeeding prevents allergy as well as providing optimal infant nutrition and other manifest benefits is not known. The total duration of breastfeeding (at least six months) may be more protective than exclusive breastfeeding for six months. (Evidence II-2B)
- Choose a hydrolyzed cow’s milk-based formula, if necessary. For mothers who cannot or choose not to breastfeed, there is limited evidence that hydrolyzed cow’s milk formula has a preventive effect against atopic dermatitis compared with intact cow’s milk formula. Extensively hydrolyzed casein formula is likely to be more effective than partially hydrolyzed whey formula in preventing atopic dermatitis. Amino acid-based formula has not been studied for allergy prevention, and there is no role for soy formula in allergy prevention. It is unclear whether any infant formula has a protective effect for allergic conditions other than atopic dermatitis. (Evidence IB)
- Do not delay the introduction of any specific solid food beyond six months of age. Later introduction of peanut, fish or egg does not prevent, and may even increase, the risk of developing food allergy. (Evidence II-2B)
- More research is needed on the early introduction of specific foods to prevent allergy. Inducing tolerance by introducing solid foods at four to six months of age is currently under investigation and cannot be recommended at this time. The benefits of this approach need to be confirmed in a rigorous prospective trial. (Evidence II-2B)
- Current research on immunological responses appears to suggest that the regular ingestion of newly introduced foods (eg, several times per week and with a soft mashed consistency to prevent choking) is important to maintain tolerance. However, routine skin or specific IgE blood testing before a first ingestion is discouraged due to the high risk of potentially confusing false-positive results. (Evidence II-2B)
I bolded some of the items that were of particular interest to me or that seemed to be different from things I've read in the media, in baby or pregnancy books, or heard as advice being passed down from one mother to another.
I think these recommendations are an important part of our individual management of allergy risk within our own families. At the same time, CPS notes that ongoing research is of course needed on the topic.
But beyond the timing of the introduction of foods, I was interested in what some of the other potential causes are for the increase in allergies. Like many other issues we are facing in our society, there must be systemic issues that are contributing to the trend. So I asked Dr. Edmond Chan, the co-author of the statement on Dietary Exposures and Allergy Prevention in High-Risk Infants for his thoughts on a couple of questions.
Q: Do we know what is causing food allergy to increase?
A: The CPS position statement is focused only on one potential contributing cause, i.e.) dietary exposures during early infancy and their potential impact on development of food allergy. The “cause” of the food allergy increase is based on a variety of genetic and environmental factors all coming together, rather than one single cause. In addition to delayed versus early exposure to foods, other environmental factors likely include: ability to manage eczematous skin, the hygiene hypothesis, and other possible factors (such as the role of probiotics, omega 3 fatty acids, vitamin D, etc).
Q: Do we know what makes food allergy more prevalent in some countries rather than others?
A: Studies suggest that food allergy is more prevalent in developed countries. This aligns with the suspected causes listed above, as data suggests that developed countries are more likely to have the mix of environmental factors which promote development of food allergy: i.e.) delayed introduction of foods, conditions which exacerbate eczematous skin, fewer germs to educate the immune system in a beneficial way, etc.
There is little that can be done about genes, but ongoing research, guidance and interventions on the other issues are particularly important in my mind. As an example, the "fewer germs" issue is one that gets raised in many other contexts as well. In addition to more allergies, there is also concern about the increased use of antibiotics (in humans and animals) and antibacterial products and the resulting increase in antibiotic resistence. On the NHS website in the UK, an article on food allergies references the rise in food allergies and notes:
One theory is that the rise in cases is due to the changes in a typical child’s diet that has occurred over the last 30 to 40 years.
Another theory is that children are increasingly growing up in "germ-free" environments. This means that their immune system may not receive sufficient early exposure to the germs it needs to develop properly. This is known as the hygiene hypothesis.
I've written before about how I'm more afraid of chemicals (in cleaning products) than germs and how my babies were healthy without Lysol (despite what the marketers of Lysol would like you to believe). I don't think that routine disinfecting is a good idea. I think it limits our children's exposure to the germs they need to be exposed to in order to develop healthy immune systems. But I wonder how we, as a society, can manage the combination of allergy risk and overdisinfecting risk? How do you ensure people who need to be exposed to germs are exposed to them while also limiting the exposure of those with developed allergies to allergens that are so dangerous to them?
I know that some of my smart readers have children with allergies and I know that many of them are also on the green/natural end of the spectrum. I'm interested in hearing from them and from all of you on the ways that we, as a society, can manage the very real risk of exposure to allergens for allergic children while also trying to prevent developing allergies in the population as a whole.
Reader Comments (33)
We are still new to managing food allergies, and are still educating ourselves and our friends and families. We trend toward the "green" end of the spectrum anyway. An important fact that we have reminded well-meaning family members of is that hand sanitizer gel/foam/etc does NOT remove allergens from their hands. We practice handwashing with regular soap and hot water. We clean our home with white vinegar , regular soap, or baking soda. We focus on clean rather than sanitized.
I'm surprised to not see mention of high levels of antibiotic use in developed countries(ie prophylactic for gbs+ and c-section deliveries), which disrupts gut bacteria biomes that aid in digestion, and gut permeability until 6 months. These are big candidates for the increased rates of food allergies. Some studies show decreased colic and reflux when babies are supplemented with probiotics.
Yeah I'd be interested to see comparative studies looking at rates of allergies and rates of c-sections and breastfeeding/formula use. Anecdotally, I was born via c-section and fed formula and nursed for a few months then exclusively formula fed and I have food intolerances and atopic dermatitis.
I gave birth naturally and breastfed for 15 months but my son has eczema and lots of allergies, including peanut. I will follow the new recommendations for baby#2 and hope for the best, but I know it's not a silver bullet amd anecdotal evidence is meaningless.
My daughter and I had a hard time getting diagnosed, being bumped around different allergy specialists, paediatricians, lactation consultants, the works. Now we know it is celiac and life is good. We avoid all gluten, being very very careful of cross contamination.
Starting kindergarten has been dreadful. They eat a communal snack off of badly washed plates. There is less than ideal table manners, which I'd love to be flexible about but grabbing off of each others plates and throwing food around is scary when food can hurt some kids so badly. Small children have added allergy risks as they trust adults (who don't always know what to do), eat with their hands, and have to eat where grown ups tell them too even if playdough was used on that table.
So the number one thing we can do as a society to make food allergies less dangerous? Everyone should wash your hands with soap and water AFTER eating.
Next, going back to the basics with food manners might help: Eat in places meant for eating; Goldfish cracker crumbs all over the library is really something scary. Teach kids to eat off their own plates and don't try and feed your friends (this happens all the time!).
Our immune disease is pretty genetic, it runs on both sides of our families for many generations of our wheat farming family. Both my children were born vaginally and breastfed long term. One has celiac and one doesn't. The breastfeeding certainly helped keep my daughter's condition under control and soothed her gut but ultimately one has to wean and that's when we saw her condition worsen.
As for my son we opted to introduce solids closer to 4 months than 6 and introduced peanut butter and almond butter early. Since we have a gluten free house hold we have left introducing gluten and grains to Grandma and the goldfish crackers on the library floor.
I have family who feel frustrated by these changes, after delaying the introduction of potential allergens, as recommended by their pediatrician. An inlaw carries a gene that puts the kids at risk for eczema, allergies and asthma, according to his doctor. You've done a great job here making clear much of what they have learned. So confusing!
@Crunchy Con Mom:
The position statement that I linked to does get into the breastfeeding vs. formula feeding issue a bit. They recommend breastfeeding (in line with other recommendations), but do not have specific randomized trials on breastfeeding vs. formula feeding as it relates to allergies, since it would be unethical to do so. However, they do have evidence from randomized trials on different types of formula as it relates to allergies.
Melanie:
Yes, that is the tough thing, of course. These recommendations are aimed to get the best possible outcome overall, but there are going to be individual cases where a child is going to have an allergy regardless of the precautions/approach that is taken. That is why I'm so interested in the overall societal changes that are contributing to greater incidence of allergies in our population. If we can address those systemic issues, hopefully the risk to individual children will be lowered over time.
It's interesting that a doctor would indicate that first introductions don't illicit reactions -- that's wholly untrue. My son was born (vaginally, without issue) and exclusively breastfed, and from birth had serious allergies (which we discovered were life-threatening). From birth, I had to follow a strict elimination diet to identify the triggers, and once he started eating solids, reactions got increasingly worse. At seven months of age he tested positive for a multitude of food allergies, and at four years of age, he has outgrown most but is still allergic to tree nuts and peanuts.
I ate nuts during both my pregnancies, and studies told me I was potentially harming my kids by doing so. Now they tell me eating more nuts is potentially protecting them?
I don't know what the answer is, I'm not sure why my one child has no allergies and my second had so many. I can theorize about why allergies exist here and nowhere else, but I don't have solid answers. And I am not sure I believe the new studies when there are so many exceptions.
I did everything "right" and I really feel like studies want to blame the mothers for this stuff, and I'm just tired of feeling like it's my fault.
Thanks for summarizing this so clearly. I will confess to being one of those parents that gave her son peanut butter in the parking lot before walking into a well child doctor's appointment. Good to know that that won't really work anyway!
While I would like to agree with everything written here, I did ALL of those recommended points with my twins and still ended up with a nut allergy in one and eczema and bee allergy in the other. I ate whatever I wanted when pregnant, we did "baby led weaning" where whole foods are offered to the babies as soon as they are interested and I did not restrict nuts or any other allergen. I let my babies roll in the grass, eat dirt, and got some pets just for the exposure to my kiddos. And with tiny twins, our home wasn't (and isnt) spot less.
My only theory left is some kind of leaky gut linked to process foods and GMOs. I have no allergies and neither does my husband. Why do our children have so many?
Are these the same guidelines if the mother has an allergy? I am allergic to dairy and eggs and kept them from my first daughters diet until she was 1 and she turned out fine. Now doing the same with my second daughter who's 10 months and spending a fortune on nutramigen dairy free formula. But should I try introducing dairy to her now? And in what form??
Hi Alex,
I am the doc you are referring to. I'm curious why you disagree with my comment that first exposures do not elicit allergic reactions.
I disagree because first exposures absolutely can result in reactions. To tell a parent that first exposure is always without reaction is untrue. Although sometimes reactions occur even after a food has been introduced safely, there is always a chance that a first exposure will result in a reaction. I know this from personal experience introducing foods to my son.
Alex:
I had two reasons for writing this post. One was to make people aware of the new recommendations. The other was to start a discussion about what the societal issues are that may be contributing to an increase in allergies. I raise that second point or issue specifically because I don't want this to be about mother-blame. I think each other is doing the best she can at the time with the available information, which is often conflicting and confusing. But I do think there is something that has changed in our collective environment or practices that has contributed to this increase. I think the sooner we start looking at that, the fewer children that will be at risk in the future.
Melanie, what is leaky gut??
Sallynoodle:
I would take a close look at the position paper and take it and discuss it with your doctor. From my read of it, these guidelines are particularly targeted at infants with higher risk for allergies (i.e. those with parents/siblings who have allergies). But I'm not a doctor -- I'm just sharing CPS' position statement and recommendations.
I definitely think increased intestinal permeability ("leaky gut") is a factor as well as imbalances in gut bacteria, which is increased in c-section babies b/c it is through vaginal delivery that the baby's intestinal flora is first colonized. Gut bacteria is being identified as a contributing factor to more and more health conditions all the time, there is some pretty interesting research being done on it.
I think it's important to note that babies by nature have increased intestinal permeability, which is designed to work in conjunction with mother's milk for optimum absorption of nutrients. The digestive system starts to 'close' partway through the first year, which is why it's desirable to wait until at least 6 months to introduce solids. I personally wouldn't recommend feeding cereal grains to babies especially in cases of familial celiac disease or gluten intolerance, as they can pass through the intestinal lining and trigger inflammation, food intolerances and also disrupt intestinal flora. We don't even start producing the enzyme needed to break them down until into the second year. With other allergens I think it's interesting that the recommendations have changed so dramatically; it was only a few years ago we were told to wait until age 4 to introduce peanuts. I haven't read anything on the changes, I will definitely check out the links you shared.
Food allergies are so scary to deal with; I know I stress over managing my daughter's many food intolerances and she can "only" get really sick (last time for a few months following an exposure). It's sad and astounding how many allergies there are in each class at school.
Hi Alex:
I have based my comments on my understanding of the physiology of allergic reactions. On that basis, it is impossible for an allergic reaction to happen without an initial exposure - also called sensitization. Prior sensitization is a necessary event in the evolution of an IgE-mediated (aka allergic) reaction. Having said that, there are situations where a child, baby, or even a fetus can get sensitized without his/her parent/caregiver knowing it. For example, in rare circumstances, a fetus can get sensitized to an allergen via passage of that allergen (in mom's blood) through the placenta into baby's blood. A baby can also get sensitized via mother's milk (e.g. mother eats peanuts and some peanut allergen gets into the mother's milk and then into baby's gut). A toddler can accidentally get the tiniest bit of peanut butter on her finger an then put it in her mouth without anyone taking notice. Then, when there is a subsequent allergic reaction, it may appear to the parent to be first exposure causing the reaction (though really there was a prior unnoticed sensitization). So ... technically, I disagree with you; it truly isn't possible to have an IgE-mediated allergic reaction without prior sensitization. However, I do agree with you in the sense that there can be situations where a child has had prior UNKNOWN sensitization. On subsequent exposure the allergic reaction occurs with it seeming to be (but truly not being) the first exposure.
My daughter is 19 months and allergic to milk (fpies), avocado, banana and latex (all ige). I am also very curious to see more research about antibiotics and leaky gut as a cause. I was treated during labor for group b strep and wonder if that was the cause. My daughter is still breastfed and I have given up her allergens as well. As the doctor mentioned, my daughter took several exposures to be fully sensitized, except for to cow's milk which she was sensitized to through my breastmilk before I cut dairy out of my diet when she was 6 weeks old. With the others, she had no reaction the first time, a mild reaction the second time that went unrecognized at first, and full reactions by the third exposure. Scary stuff. I hate allergies. I hope more research is done soon, for all the families who have to live this way.
My first daughter was diagnosed allergic to wheat, dairy, eggs and nuts. The second to corn and potatoes. It took some accommodating to say the least. Despite having studied nutrition in graduate school, our case put me head first into studying everything I could to make sense of causation. I can't help but to compare how we eat today, and the environment in which we gestate and raise our children, and the environment our distant ancestors raised theirs, and how we've evolved. Our immune systems have developed to work with bacteria, good and bad, which we should be introduced to, both in our environment and through our food. We have disinfected our living spaces, and killed most all good bacteria in our food, leaving our childrens' immune system to look for a fight. Could this system that we still know so little about, in a world with millions upon millions of microorganisms we know so little about, just get bored, and decide to fight what is left to fight, being the foods we commonly eat? I think this is the case. I feel my kids are stuck with the afflictions that they have...and their blood and rast tests are not getting any better. At this point, I feel all I can do is encourage getting dirty, sneak in the probiotics, preferably through home fermentation, and turn to introduction of medicinal mushrooms like Chaga and Reishi. Let's see what happens. Wildforaged.com
This was so interesting and I'm still so confused about it all. My first three have no allergies, but my fourth is allergic to eggs and peanuts. He has never had a reaction . . . his last test was a year ago. We're going back in. I'm hoping this time the tests show he's not allergic, but I suppose that's being overly optimistic.
I believe that the key to this is to let your kids eat these foods once in a while to gain immunity. I was once allergic to fish so I occasionally eat that until my body accepted it.
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My child has no known food allergies, and I'm so grateful!
I wanted to add to Katy's important point about hand sanitizer not removing food allergens from your hands: If you are allergic to mold, washing with soap and water probably is the better way to remove that, too. My Girl Scout troop's experiment with different forms of hand cleaning indicated that alcohol-based hand sanitizer does not kill mold spores. We were surprised!
Hi Annie, thought you'd be interested to know about our upcoming documentary The Allergy Fix which will air Feb 27 on CBC's The Nature of Things. It looks at the current scientific research into allergies. I will send you a link to the trailer as soon as it's ready.
I had no idea allergies were so prevalent. Nobody in my family is allergic to anything. Wow, we must be lucky :)
When discussing allergens with a mom, who is also a homeopath, she mentioned she has read some articles that suggest there is a link between peanut allergies being on the rise and a peanut protein being used in vaccines. (See link: http://neurosciencemyths.com/10-02-Vaccinesfinal.pdf) I'm pro vaccines, as I believe the benefits outweigh the burden. (Unfortunately there are some serious side effects for some vaccine receivers.) All I can hope for is that ethical studies are done in this regard and in all areas of medicine. The truth is more important than the bottom line.
Really interesting and educating read. It seems like there are so many factors which parents have to be aware of to give their children the best chance of staying allergy free. Thanks so much for sharing this valuable information.
From Holland: since 31th of january we have a new protocol in Holland to decrease the incidence of food-allergies by advising parents to exclusively breastfeed for 4 months instead of 6 months. This advice is being given by our government and claims to be 'science based'. I checked the used references and found that some of them were misinterpreted, leading to a false conclusions and various papers were ignored. From the articles I read I learned that for gluten and potato there is reason to believe that introduction (of small amounts) at around 5 months could be beneficial. For all other types of food, the introduction at 6 months seems optimal. One of the key referenced study (!!) state that introduction of various food-types at a time at 4 months increases the risk of allergies! Various studies also show that early introduction of other foods also lowers the total duration of breastfeeding (and thus its health benefits). I wrote letter about it when it was still in concept . The authors of the advice responded they did not 'mean' to decrease the amount of breastfeeds between 4-6 months, although not giving any advice on the amounts or number of the different foods to be given to the babies (would this be too complicated to tell parents??). Also they say that 6 months exclusive breastfeeding (WHO-advice) is only beneficial for countries with poor health facilities and no clean water. So now in Holland you are being told by the health-workers you do a poor job giving your child 6 months exclusive breastfeeding, because you would risk food allergies. It's mad!
My daughter was born with heart problems. With this comes a bit of a weakened immune system. We just brought her home from the hospital the other day. Are there any allergens that we need to be extra mindful of in her situation? We are thinking in regards to store bought milk formulas.
http://www.allergyclinicidaho.com/get-tested-in-the-off-season/
Suffering from allergy from toddlerhood and having asthmatic attacks on a regular basis in childhood made me very wary in trying to prevent my daughter from developing allergies.
The pregnancy was as chemical free as possible (once we found out), to ensure that there is no chemical exposure before birth. Apart from that my diet included all of the allowed foods and was well balanced (high protein intake), supplemented by DHA, folic acid and prenatal vitamins. We had natural, completely drug-free labour, that also included no antibiotics being administered to the baby after birth.
We only used organic Weleda products on our daughter's skin. We exclusively breastfed until 6 months, allowing exposure to allergens after 6th month and introduced baby-led weaning when she was ready at nearly 8 months. The only thing we have never given her are shellfish as we don't really eat that ourselves. We are breastfeeding still at 19 months to ensure she gets all that can help her with any possible allergies (on top of other benefits coming from breastfeeding). We use cloth diapers to exclude contact allergies. I eat organic for as long as I'm pregnant/breastfeeding, so does she.
The only cleaning products we use in our house are Ecover products, apple cider vinegar and soda. I went as far as to using only Aleppo soap on myself, washing my hair in baking soda and vinegar, for the rest using Weleda products and no perfumes since we found out about pregnancy. We keep the house fairly clean (also because of my horrible dust allergy), we have a cat that she plays daily with it. She plays in the garden nearly every day (and digs in soil, after that puts her hands in her mouth, etc.). We allow her to eat what she dropped on the floor (we're not scared of germs, as we don't sanitize the house, thus we keep it clean, but not sterile and we don't allow to have super-germs like ones you can find in hospitals=no need to worry about bacteria). We allow her to eat sth even when her hands aren't clean on a daily basis. She has never been ill (if you don't count mild ear infection as an infant), never gotten any antibiotics either. Only thing she was ever given is Nurofen for children (acetaminophen, this one doesn't have a colourant), vitamin K, orally, as an infant and vitamin D until she is 6 yo. We don't use anything plastic to cook or store our food (minimising chemical exposure).
She has developed allergies. Despite all our efforts. I suppose sometimes genes are just to powerful and there is only this much you can do to minimise symptoms or amount of allergies. She is doing great as long as she doesn't get clementines (extremely irritiating to her bowels upon minimal amount, also giving her hives and burnt skin upon contact with the diarrhoea). Strawberries give her mild eczema, so we stopped offering those as we don't want the same story as with clementines. I'm just hoping that the list ends here. I'm looking forward to more research on this subject as I know how terrifying and downright crippling severe allergies can be for a child, teenager and even young adult (my younger sister still has very severe atopic eczema at an age of 23 despite all the treatment from infancy on).
To respond to Laura,
I'm a RDN and IBCLC w/ a master's in clinical nutrition. I did my thesis on celiac and breastfeeding. When a child is born carrying the gene for celiac, it isn't necessarily "turned on". It is recommended that you introduce gluten (gliadin) while still breastfeeding. This will lessen the likelihood that celiac will be "trigger or turned on" in that infant.
I recall from the literature that only 1 in 4 people w/ the gene for celiac will actually develop the disease.
Wish you the best, I know (as a mother w/ celiac disease) that it's terribly scary and difficult to manage at times.
http://thinkingmomsrevolution.com/whats-really-behind-peanut-allergy-epidemic/
I'm so tired of "Blame the parents" theories on how our entire country has increased in the number of food allergies. These allergies were virtually non existent several decades ago. The numbers have increased along with vaccination rates. Vaccines contain peanut oil or proteins that are almost molecularly identical. Why aren't vaccines being investigated???